(Select all that apply - Online ATI/HESI question): A nurse is performing sterile suctioning on a patient. Which of the following are appropriate infection control measures for this procedure? Select all that apply.
Environmental cleaning before suctioning.
Using a reusable suctioning catheter.
Proper disposal of used catheters into a regular trash bin.
Hand hygiene before and after the procedure.
Wearing gloves and a mask during suctioning.
Correct Answer : A,D,E
Choice A rationale:
Environmental cleaning before suctioning is crucial to maintain a clean and safe environment for the patient. This reduces the risk of introducing additional contaminants during the procedure.
Choice B rationale:
Using a reusable suctioning catheter is not appropriate for infection control measures. Reusable catheters can harbor microorganisms, even after proper cleaning and sterilization, increasing the risk of cross-contamination.
Choice C rationale:
Proper disposal of used catheters into a regular trash bin is not a suitable infection control measure. Used catheters should be disposed of in designated biohazard containers to prevent exposure to potential pathogens.
Choice D rationale:
Hand hygiene before and after the procedure is essential to reduce the transmission of microorganisms to and from the patient.
Choice E rationale:
Wearing gloves and a mask during suctioning helps protect the nurse from exposure to the patient's bodily fluids and potential infectious agents.
Repeat steps 7 to 9 until no more secretions are obtained or until three passes are completed. Do not suction more than three times in a row to prevent complications. Allow at least one minute of rest between each suction pass to prevent fatigue and distress .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C rationale:
The nurse should acknowledge the patient's anxiety and respond empathetically. Assuring the patient that the nurse will explain each step during the procedure can help alleviate anxiety. This approach promotes trust and helps the patient feel more in control, which is important for patient cooperation during the suctioning procedure.
Choice A rationale:
Telling the patient not to worry and that it won't take long may come across as dismissive and not address the patient's concerns adequately.
Choice B rationale:
Offering to postpone the procedure is an option, but the nurse should first attempt to address the patient's anxiety and provide reassurance. If the anxiety persists despite the explanation, postponing the procedure can be considered.
Choice D rationale:
Dismissing the patient's anxiety by stating that suctioning is routine may not effectively address the patient's feelings and may not be comforting.
Correct Answer is D
Explanation
Choice A rationale:
Cleaning the inner cannula once a week is insufficient to maintain proper hygiene for a patient with a tracheostomy tube. The inner cannula should be cleaned more frequently, as directed by the healthcare provider, to prevent the accumulation of secretions and potential respiratory complications.
Choice B rationale:
Deflating the cuff before cleaning the tracheostomy tube is not recommended because it may lead to aspiration of secretions or loss of the airway seal. The cuff should only be deflated when it is necessary to remove or change the tracheostomy tube.
Choice C rationale:
Using cotton-tipped applicators to clean the stoma is not the recommended method for tracheostomy care. Sterile tracheostomy care kits usually include specialized brushes or swabs designed for this purpose, ensuring effective and safe cleaning of the stoma without the risk of shedding fibers or causing injury.
Choice D rationale:
Changing the tracheostomy ties every 24 hours is the appropriate action. Regular changing of the ties helps prevent complications such as skin breakdown, ensures a secure fit of the tracheostomy tube, and reduces the risk of infection.
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